What is the Fagerstrom test for nicotine dependence?

Answer: The Fagerstrom test is a short, self report survey used for psychiatric assessment of a person’s dependence on nicotine use.

Fagerstrom test nicotine dependence

Nicotine is the highly addictive principle psychoactive ingredient of tobacco. In people with tobacco addictions such as smoking or chewing tobacco usage, they often develop physical and psychological dependence to the substance. When they are dependent on the drug, they feel that they must obtain and use the drug frequently.

The Fagerstrom test is a six question self report test that is often used to assess the severity of a person’s dependence. The test itself consists of yes / no questions and multiple choice questions. Each yes adds 1 point to a patient’s running total, and each multiple choice answer adds some number up to 3 to the total. The higher the final total, the more severe the person’s level of dependence.

The questions are designed to assess the amount of drug that is used and the drive to continue using nicotine. The first test was designed by Karl-Olov Fagerstrom, and it was initially designed to assess dependence on a general substance. In 1991, the Fagerstrom test was redesigned by Todd Heatherton to specifically target nicotine dependence.

fagerstrom test quit smoking

Fagerstrom Test for Nicotine Dependence

Question 1. How soon after waking up do you smoke your first cigarette of the day?

After 60 minutes: 0 points
31 to 60 minutes: 1 point
6 to 30 minutes: 2 points
Less than 5 minutes: 3 points

Question 2. Do you find it difficult to refrain from smoking in places where it is forbidden?

No: 0 points
Yes: 1 point

Question 3. Which cigarette would you most hate to give up?

The first one in the morning: 1 points
Any other: 0 points

Question 4. How many cigarettes do you smoke per day?

10 or fewer: 0 points
11 to 20: 1 points
21 to 30: 2 points
31 or more: 3 points

Question 5. Do you smoke more in the early hours after first waking than the rest of the day?

Yes: 1 point
No: 0 points

Question 6. Do you smoke even if you are so ill that you cannot get out of bed?

Yes: 1 point
No: 0 points

Interpretation of results

  • Fewer than 3 points: Your level of nicotine addiction is still relatively low. It is a good time to act to minimize future harm before you become severely addicted.

  • 4 to 5 points: You are moderately addicted. It will be more difficult to quit smoking since the dependence has become more severe than a mild smoker. Reducing nicotine intake will be a helpful step towards improving your health over the long term and immediate term.

  • More than 6 points: Your nicotine dependence is severe. Your health will be best improved by finding ways to decrease cigarette usage through nicotine replacement therapies or pharmacological strategies. Consider using a nicotine gum, patch, electronic cigarettes, or a nicotine mouth spray in place of a normal cigarette.

The questions on the Fagerstrom test generally align with many of the criteria as outlined by the Diagnostic and Statistical Manual of Mental Disorders for substance use disorders. For example, question 2 asking about stopping smoking where it is prohibited is similar to the criteria of using a substance even though it might be related to personal loss. As another example, question 6 is related to the continuation of drug usage even though there are negative health consequences.

The health risks associated with cigarette addiction are severe, and even more so if your level of dependence is high. The consequences associated with chronic nicotine use include an elevated risk of developing a variety of cancers of the lung, throat, and mouth, worsening outcomes for cardiovascular health, and difficulty with breathing that may manifest as chronic obstructive pulmonary disease (COPD).

Nicotine addiction is a severe brain condition. Exposure to nicotine causes tremendous changes in neural circuitry, also called plasticity in the brain, as it rewires itself in the presence of nicotine. But, there are methods which may decrease the likelihood of becoming further addicted. These strategies are also effective at decreasing cigarette dependence, which can help some users quit smoking.

Nicotine replacement strategies

A nicotine replacement therapy is one that aims to stop cigarette addiction by delivering nicotine to the brain, decreasing the exposure to the dangerous byproducts of cigarette smoke. Since nicotine is the ingredient that the addicted brain craves, the replacement of nicotine with one of these strategies acts to reduce the cravings by delivering nicotine. A person scoring high on the Fagerstrom test indicates that a person may have difficulty quitting cigarettes even with the help of nicotine replacement therapies.

Some of the most well known NRTs include the nicotine patch, which a user puts on their body. From there, the drug diffuses through the skin and into the bloodstream. This route of administration, transdermal, is very good at getting drug into the brain very slowly over a long period of time. As a result, the brain levels of nicotine are maintained over some duration.

Another nicotine replacement therapy is the nicotine gum. With nicotine gum, the user gets nicotine delivered into their blood through an oral route, usually by absorption through the oral mucosal membranes.

Non nicotine replacement strategies

The non-NRT approaches to smoking cessation are pharmacological methods. Two of the main compounds that are used include Zyban (bupropion) and Chantix (varenicline).

Zyban was originally used as an antidepressant, but it was discovered to serve a function as smoking cessation tool. It’s primary pharmacological action is to inhibit the reuptake of norepinephrine and dopamine (NDRI). These drugs act to increase the duration of both norepinephrine and dopamine at the synapse, increasing total signaling of these neurotransmitters. It also acts as an antagonist at a variety of nicotinic receptors.

Chantix (varenicline) is a nicotinic acetylcholine receptor partial agonist. When varenicline is in the body, it activates nicotinic receptors to a moderate degree, resulting in a low level of dopamine release. Normal use of nicotine increases dopamine dramatically, but with varenicline present, it blocks the action of much of the nicotine that is in the bloodstream. In doing so, varenicline makes nicotine less rewarding while still activating the dopaminergic terminals that are relevant for reward. Varenicline, as of the time of writing, provides the best odds for smoking cessation, although it is still an extremely difficult habit to stop.